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Zhu X, Liu Y, Yang X, Liu B, Zhang X. Identifying subcutaneous tissue microcalcification by Fluo-3 AM imaging in cutaneous calciphylaxis. Exp Dermatol 2022; 31:1632-1634. [PMID: 35441735 DOI: 10.1111/exd.14579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/10/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022]
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy (CUA), is typically characterized by subcutaneous tissue calcification and excruciatingly painful cutaneous lesions with high mortality. It is critical for dermatologists to make early diagnosis and appropriate management, yet currently only 56% of calciphylaxis cases would be correctly diagnosed by conventional histological stain1.Specially, the identification of subtle calcium deposits of subcutaneous can be challenging but is believed crucial for early diagnosis of calciphylaxis2. More sensitive calcification staining is in high demand. In this study, Fluo-3 AM was found to be a rapid, sensitive and reliable fluorescent probe for the detection of calcium deposits, and could be a promising diagnostics tool for calciphylaxis.
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Affiliation(s)
- Xiaodong Zhu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine
| | - Yuqiu Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine
| | - Xin Yang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine
| | - Bicheng Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine
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2
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Gabel CK, Blum AE, François J, Chakrala T, Dobry AS, Garza-Mayers AC, Ko LN, Nguyen ED, Shah R, John JS, Nigwekar SU, Kroshinsky D. Clinical mimickers of calciphylaxis: A retrospective study. J Am Acad Dermatol 2021; 85:1520-1527. [PMID: 33744358 DOI: 10.1016/j.jaad.2021.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/25/2021] [Accepted: 03/06/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Calciphylaxis is an ischemic vasculopathy with high morbidity and mortality. Early and accurate diagnosis is critical to management of calciphylaxis. Clinical mimickers may contribute to delayed or misdiagnosis. OBJECTIVE To assess the rate and risk factors for misdiagnosis and to identify clinical mimickers of calciphylaxis. METHODS A retrospective medical record review was conducted of patients with calciphylaxis at a large urban tertiary care hospital between 2006 and 2018. RESULTS Of 119 patients diagnosed with calciphylaxis, 73.1% were initially misdiagnosed. Of patients not initially misdiagnosed, median time to diagnosis from initial presentation was 4.5 days (interquartile range, 1.0-23.3), compared to 33 days (interquartile range, 13.0-68.8) in patients who were initially misdiagnosed (P = .0002). The most common misdiagnoses were cellulitis (31.0%), unspecified skin infection (8.0%), and peripheral vascular disease (6.9%). Patients who were misdiagnosed frequently received at least 1 course of antibiotics. Patients with end-stage renal disease were less likely to be misdiagnosed than those without this disease (P = .001). LIMITATIONS Single-center, retrospective study. CONCLUSIONS Understanding the risk factors for misdiagnosis of calciphylaxis is an opportunity for further education concerning this rare disease.
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Affiliation(s)
- Colleen K Gabel
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy E Blum
- Harvard Medical School, Boston, Massachusetts
| | | | - Teja Chakrala
- Narayana Medical College and Hospital, Nellore, India
| | - Allison S Dobry
- Department of Dermatology, University of California, Irvine School of Medicine, Irvine, California
| | | | - Lauren N Ko
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Emily D Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Radhika Shah
- Department of Dermatology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jessica St John
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sagar U Nigwekar
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts.
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3
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Gabel CK, Chakrala T, Dobry AS, Garza-Mayers AC, Ko LN, Nguyen ED, Shah R, St. John J, Nigwekar SU, Kroshinsky D. The Koebner phenomenon may contribute to the development of calciphylaxis: A case series. JAAD Case Rep 2021; 13:57-61. [PMID: 34159240 PMCID: PMC8193369 DOI: 10.1016/j.jdcr.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Colleen K. Gabel
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Teja Chakrala
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Allison S. Dobry
- Department of Dermatology, University of California, Irvine School of Medicine, Irvine, California
| | | | - Lauren N. Ko
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Emily D. Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Radhika Shah
- Department of Dermatology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jessica St. John
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sagar U. Nigwekar
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
- Correspondence to: Daniela Kroshinsky, MD, MPH, Department of Dermatology, Massachusetts General Hospital, 50 Staniford Street, 2nd Floor, Boston, MA 02114.
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4
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Rrapi R, Chand S, Gabel C, Ko L, Moore KJ, Steele D, Kroshinsky D. Early diagnosis and intervention of calciphylaxis leading to rapid resolution. JAAD Case Rep 2021; 13:65-70. [PMID: 34169132 PMCID: PMC8207171 DOI: 10.1016/j.jdcr.2021.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Renajd Rrapi
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sidharth Chand
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Colleen Gabel
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lauren Ko
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kevin J Moore
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - David Steele
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
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Diasty ME, Cuenca J. New-onset acute rapidly deteriorating case of calciphylaxis after open heart surgery: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab060. [PMID: 33748662 PMCID: PMC7955961 DOI: 10.1093/ehjcr/ytab060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/23/2020] [Accepted: 01/25/2021] [Indexed: 11/30/2022]
Abstract
Background Calciphylaxis is a rare life-threatening condition that is characterized by calcification of small blood vessels and soft tissues. This condition is classically described in uraemic patients with end-stage renal failure who are on dialysis or had previous renal transplant. It has also been reported in non-uraemic patients and those who are on warfarin therapy. It is typically associated with high calcium/phosphorus product. Patients classically present with painful skin lesion that evolve into painful ulcers. There are multiple risk factors that were reported to trigger or worsen calciphylaxis. Treatment is a multidisciplinary approach that involves elimination of risk factors, wound management, pain control, and optimization of calcium/phosphorus metabolism. Reported mortality rates are very high especially in the uraemic group. Case summary Here we present a case of a patient, who is on chronic renal dialysis for stage renal failure, who underwent mechanical mitral valve replacement and tricuspid valve repair. In the perioperative period, she was exposed to multiple risk factors that are known to potentially trigger prophylaxis. In the early postoperative period, she developed new-onset rapidly deteriorating skin lesions and the histopathological diagnosis confirmed calciphylaxis. Her treatment plan included pain control, frequent wound care, and optimization of nutritional and metabolic status. Discussion Calciphylaxis is a very serious condition that is usually associated with poor outcome. In this case, we discuss the unusual presentation of this condition with particular emphasis on the multiple perioperative risk factors that can potentially trigger the onset of calciphylaxis in postoperative cardiac patients. We also discuss the epidemiology, pathogenesis, diagnosis, histopathological findings, and different lines of treatment of this serious condition and the potential preventative strategies.
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Affiliation(s)
- Mohammad El Diasty
- Cardiac Surgery Department, Kingston Health Science Centre, 76 Stuart Street, Kingston, ON K7L 2V7, Canada
| | - Jose Cuenca
- Cardiac Surgery Department, Hospital San Rafael, Ls Jubias, 82, 15009 A Coruna, Spain
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6
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Assessment of outcomes of calciphylaxis. J Am Acad Dermatol 2020; 85:1057-1064. [PMID: 33130181 DOI: 10.1016/j.jaad.2020.10.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Calciphylaxis is a rare thrombotic vasculopathy characterized by high morbidity and mortality. There is a paucity of studies examining longitudinal outcomes. OBJECTIVE To assess mortality, days spent in the hospital, and amputations in patients with calciphylaxis. METHODS A retrospective medical record review was conducted in 145 patients diagnosed with calciphylaxis at an urban tertiary care hospital from January 2006 to December 2018. RESULTS Six-month mortality was 37.2%, and 1-year mortality was 44.1%. Patients with nephrogenic calciphylaxis had worse survival than those with nonnephrogenic calciphylaxis (P = .007). This difference in survival disappeared when limiting mortality to deaths due to calciphylaxis. Age (P = .003) and end-stage renal disease (P = .01) were risk factors associated with 1-year mortality. Diabetes mellitus was associated with greater total hospitalization days (coefficient, 1.1; 95% confidence interval, 1.01-1.4); bedside debridement was associated with fewer hospitalization days (coefficient, 0.8; 95% confidence interval, 0.7-0.9). Amputations were not associated with any of the examined risk factors. The use of warfarin followed by a transition to nonwarfarin anticoagulation was associated with decreased hazard of death (P = .01). LIMITATIONS Retrospective nature. CONCLUSIONS Calciphylaxis remains a complex, heterogeneous disease. Mortality is lower in patients with nonnephrogenic disease. These findings may be incorporated during discussions regarding the goals of care to facilitate informed shared decision making.
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7
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Ruderman I, Hewitson TD, Smith ER, Holt SG, Wigg B, Toussaint ND. Vascular calcification in skin and subcutaneous tissue in patients with chronic and end-stage kidney disease. BMC Nephrol 2020; 21:279. [PMID: 32677907 PMCID: PMC7364566 DOI: 10.1186/s12882-020-01928-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/05/2020] [Indexed: 12/15/2022] Open
Abstract
Background Vascular calcification (VC) is well described in large- and medium-sized vessels in patients with chronic kidney disease (CKD), especially in those with end-stage kidney disease (ESKD) on dialysis. Medial calcification is particularly prevalent in this population and contributes to arterial stiffness and increased cardiovascular mortality and morbidity. Apart from in the setting of calciphylaxis, few studies have assessed skin and subcutaneous calcification and associations with abnormalities of bone and mineral metabolism in patients with CKD. Methods We performed a single-centre observational study to evaluate incisional skin tissue samples from three anatomical sites in patients with different stages of CKD undergoing elective surgery. We compared these samples to skin samples of a control cohort without CKD. Staining for calcification was performed with von Kossa method. A subgroup of skin samples were assessed by RT-PCR for upregulation of pro-calcific gene transcripts for tissue non-specific alkaline phosphatase (TNAP) and Runt-related transcription factor 2 (RUNX2). Results Forty-five patients were evaluated, 34 with CKD (including ESKD) and 11 control patients. VC was identified in 15 skin samples (13 CKD/ESKD and 2 controls). VC was present in the dermal and subcutaneous tissues of the neck, abdomen and arm samples. Two different histological types of VC were identified: speckled medial calcification and internal elastic lamina calcification. Presence of perieccrine calcification was identified in 14 samples, 10 with concurrent VC. There were no significant differences in serum parathyroid hormone, phosphate or calcium in patients with or without VC. Expression of TNAP or RUNX2 was not increased in samples from patients with ESKD or those with histological evidence of calcification. Conclusion This study reports the novel finding of dermal and subcutaneous calcification in multiple anatomical locations in 38% of patients with advanced CKD/ESKD undergoing elective surgery but free from calciphylaxis.
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Affiliation(s)
- Irene Ruderman
- Department of Nephrology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia. .,Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia.
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia.,Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia.,Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia.,Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Belinda Wigg
- Department of Nephrology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia.,Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
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8
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Gabel C, Chakrala T, Shah R, Danesh MJ, Dobry AS, Garza-Mayers AC, Ko LN, Nguyen E, St John J, Walls AC, Nigwekar SU, Song PI, Kroshinsky D. Penile calciphylaxis: A retrospective case-control study. J Am Acad Dermatol 2020; 85:1209-1217. [PMID: 32422224 DOI: 10.1016/j.jaad.2020.05.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Calciphylaxis is a rare disorder characterized by skin necrosis caused by calcium deposition within vessels, thrombosis, and subsequent tissue ischemia. Penile involvement may rarely occur. OBJECTIVE To identify risk factors, diagnosis, management, and mortality of patients with penile calciphylaxis. METHODS A retrospective medical record review was conducted of 16 patients with penile calciphylaxis treated at 2 large urban tertiary care centers between January 2001 and December 2019. A control group of 44 male patients with nonpenile calciphylaxis at the same institution was included. RESULTS The median survival of patients with penile calciphylaxis was 3.8 months (interquartile range, 27.0 months). Mortality was 50% at 3 months and 62.5% at 6 months for penile calciphylaxis, and 13.6% at 3 months and 29.5% at 6 months for controls (P = .008). Patients with penile calciphylaxis were less likely to be obese (P = .04) but more likely to have hyperparathyroidism (P = .0003) and end-stage renal disease (P = .049). LIMITATIONS Retrospective study design and small sample size. CONCLUSIONS This study further defines the disease course of penile calciphylaxis, which has high mortality. Imaging may be used to aid diagnosis. Risk factors include end-stage renal disease, hyperparathyroidism, and normal body mass index.
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Affiliation(s)
- Colleen Gabel
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Teja Chakrala
- Narayana Medical College and Hospital, Nellore, India
| | - Radhika Shah
- Department of Dermatology, Robert Wood Johnson Medical School, New Brunswick
| | - Melissa J Danesh
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Allison S Dobry
- Department of Dermatology, University of California, Irvine School of Medicine, Irvine, California
| | | | - Lauren N Ko
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Emily Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica St John
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Andrew C Walls
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sagar U Nigwekar
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Philip I Song
- Department of Dermatology, Palo Alto Medical Foundation, Palo Alto, California
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts.
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9
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Lee SJ, Lee IK, Jeon JH. Vascular Calcification-New Insights Into Its Mechanism. Int J Mol Sci 2020; 21:ijms21082685. [PMID: 32294899 PMCID: PMC7216228 DOI: 10.3390/ijms21082685] [Citation(s) in RCA: 195] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/10/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023] Open
Abstract
Vascular calcification (VC), which is categorized by intimal and medial calcification, depending on the site(s) involved within the vessel, is closely related to cardiovascular disease. Specifically, medial calcification is prevalent in certain medical situations, including chronic kidney disease and diabetes. The past few decades have seen extensive research into VC, revealing that the mechanism of VC is not merely a consequence of a high-phosphorous and -calcium milieu, but also occurs via delicate and well-organized biologic processes, including an imbalance between osteochondrogenic signaling and anticalcific events. In addition to traditionally established osteogenic signaling, dysfunctional calcium homeostasis is prerequisite in the development of VC. Moreover, loss of defensive mechanisms, by microorganelle dysfunction, including hyper-fragmented mitochondria, mitochondrial oxidative stress, defective autophagy or mitophagy, and endoplasmic reticulum (ER) stress, may all contribute to VC. To facilitate the understanding of vascular calcification, across any number of bioscientific disciplines, we provide this review of a detailed updated molecular mechanism of VC. This encompasses a vascular smooth muscle phenotypic of osteogenic differentiation, and multiple signaling pathways of VC induction, including the roles of inflammation and cellular microorganelle genesis.
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Affiliation(s)
- Sun Joo Lee
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, Korea;
| | - In-Kyu Lee
- Leading-edge Research Center for Drug Discovery and Development for Diabetes and Metabolic Disease, Kyungpook National University Hospital, Daegu 41404, Korea;
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea
| | - Jae-Han Jeon
- Leading-edge Research Center for Drug Discovery and Development for Diabetes and Metabolic Disease, Kyungpook National University Hospital, Daegu 41404, Korea;
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea
- Correspondence: ; Tel.: +82-(53)-200-3182; Fax: +82-(53)-200-3155
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10
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Clinicopathologic Features and Calcium Deposition Patterns in Calciphylaxis: Comparison With Gangrene, Peripheral Artery Disease, Chronic Stasis, and Thrombotic Vasculopathy. Am J Surg Pathol 2020; 43:1273-1281. [PMID: 31192861 DOI: 10.1097/pas.0000000000001302] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Diagnosis of calciphylaxis is crucial, yet its distinction from other vascular diseases can be challenging. Although vascular calcification and thrombosis are hallmarks of calciphylaxis, the incidence and patterns of these features in other vascular diseases have not been well characterized. The specificity of fine calcium deposits in vessel walls (identifiable on von Kossa [VK] stain only) and other extravascular calcifications is not entirely clear. We retrospectively examined the clinicopathologic features in calciphylaxis (n=27), gangrene and viable skin at amputation margin (n=20 each), chronic stasis (n=22), and thrombotic vasculopathy (n=19) to identify useful discriminators. Calcification of subcutaneous small vessels appreciable on hematoxylin and eosin stain was relatively specific for calciphylaxis, although sensitivity was low (56%). VK detected fine calcium deposits in vessel walls not appreciable on hematoxylin and eosin, however, specificity was limited by frequent finding of similar deposits in peripheral artery disease. Combining calcium deposits detected by VK and thrombosis of subcutaneous small vessels resulted in optimal sensitivity (85%) and specificity (88%) for calciphylaxis. Similar observations applied to medium-sized vessel calcification. Calcification of eccrine gland basement membranes, elastic fibers, and perineurium did not effectively distinguish calciphylaxis from other groups. Diffuse dermal angiomatosis was exclusively found in calciphylaxis in this study. In conclusion, VK is useful in enhancing the detection of vascular calcification and avoiding the false-negative diagnosis, but this finding requires concomitant subcutaneous small vessel thrombosis to support a diagnosis of calciphylaxis. Diffuse dermal angiomatosis should increase suspicion for underlying calciphylaxis and prompt deeper sampling in the appropriate clinical setting.
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11
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Adapa S, Naramala S, Gayam V, Koduri NM, Daggubati SR, Patel P, Konala VM. Calciphylaxis in a Patient on Home Hemodialysis. J Investig Med High Impact Case Rep 2020; 8:2324709620922718. [PMID: 32434389 PMCID: PMC7243381 DOI: 10.1177/2324709620922718] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Calciphylaxis is a rare and severe complication characterized by calcification of arterioles and capillaries in the dermis and subcutaneous adipose tissue that leads to ischemia, necrosis, and painful skin lesions in patients with end-stage renal disease (ESRD). It is also known as calcific uremic arteriolopathy. Calciphylaxis occurs most commonly with the ESRD with skin ulceration as a predominant presenting feature. Calcium-phosphorus dysregulation in dialysis patients are traditionally considered as a risk factor for the development of calciphylaxis. The involvement of an integrated interdisciplinary and multifaceted approach is key to the success of the calciphylaxis treatment. We present a case of a 51-year-old female with ESRD on home hemodialysis who developed calciphylaxis, which was successfully managed with increasing dialysis prescription, diligent wound care, and sodium thiosulfate infusion. Management of calciphylaxis in a patient receiving home hemodialysis has never been reported as per the review of the literature. Calciphylaxis is a sporadic disease, frequently encountered in the patients undergoing hemodialysis and carries a very grave prognosis. Current treatment is rarely effective, so preventive strategies play an important role by modifying the risk factors that promote the development of calciphylaxis.
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Affiliation(s)
- Sreedhar Adapa
- The Nephrology Group Inc, Fresno, CA, USA
- Sreedhar Adapa, Kaweah Delta Medical Center, 400 West Mineral King Avenue, Visalia, CA 93291-6263, USA.
| | | | - Vijay Gayam
- Interfaith Medical Center, New York, NY, USA
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12
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David R, Nowicki J, Lee J, Dean N. Penile gangrene due to calciphylaxis: a multidisciplinary approach to a complex clinical challenge. BMJ Case Rep 2019; 12:12/12/e232138. [PMID: 31811092 DOI: 10.1136/bcr-2019-232138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Penile calciphylaxis is a rare but clinically challenging condition to manage. While multiple treatment options have been proposed, the underlying evidence is anecdotal, and the overall prognosis remains extremely poor. We describe the case of a patient who underwent urgent debridement of a suspected gangrenous penile tip, who was intraoperatively found to have penile calciphylaxis. The necrosis progressed and the patient had a glans amputation. A non-healing wound developed, requiring reconstruction with two skin grafts using foreskin by the plastic and reconstructive surgical unit. The patient was commenced on sodium thiosulfate and his wound had completely healed 2 months following his last operation. We review the literature to determine the biochemical features, management options and outcomes in patients with penile calciphylaxis.
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Affiliation(s)
- Rowan David
- Urology Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jake Nowicki
- Plastic and Reconstructive Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jason Lee
- Urology Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nicola Dean
- Plastic and Reconstructive Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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13
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Abstract
Inflammatory skin diseases encompass a vast array of conditions. The field continues to expand and evolve with resurgence of conditions, through newly recognized medication adverse effects, and via more detailed descriptions of known dermatoses. The importance of clinicopathologic correlation and an up to date knowledge of dermatologic conditions cannot be overstated. This review focuses on an array of recent important developments in the histologic diagnosis of inflammatory conditions that affect the skin.
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14
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Abstract
Non-neoplastic skin lesions comprise a sizable group of disorders with variable etiologies and clinical manifestations. They can be grouped into vesiculopustular dermatitides; spongiotic and psoriasiform diseases; lichenoid dermatitides; lymphoid infiltrates of the dermis; granulomatous processes; bullous disorders; vasculopathies; panniculitides; deposition disorders; and defects in maintenance of dermal connective tissue. The use of histochemical methods continues to be an indispensable adjunct to conventional microscopy in the further characterization of such lesions. This review considers that topic.
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Affiliation(s)
- Mark R Wick
- Division of Surgical Pathology & Cytopathology, University of Virginia Medical Center, 1215 Lee Street, Charlottesville, VA 22908-0214, USA.
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15
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Williams EA, Moy AP, Cipriani NA, Nigwekar SU, Nazarian RM. Factors associated with false-negative pathologic diagnosis of calciphylaxis. J Cutan Pathol 2018; 46:16-25. [DOI: 10.1111/cup.13364] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 08/03/2018] [Accepted: 09/19/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Erik A. Williams
- Massachusetts General Hospital; Dermatopathology Unit, Department of Pathology; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
| | - Andrea P. Moy
- Department of Dermatology; Northwell Health and Zucker School of Medicine at Hofstra/Northwell; Lake Success New York
| | - Nicole A. Cipriani
- The University of Chicago Medicine & Biological Sciences; Chicago Illinois
| | - Sagar U. Nigwekar
- Harvard Medical School; Boston Massachusetts
- Massachusetts General Hospital; Division of Nephrology, Department of Medicine; Boston Massachusetts
| | - Rosalynn M. Nazarian
- Massachusetts General Hospital; Dermatopathology Unit, Department of Pathology; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
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16
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García-Lozano JA, Ocampo-Candiani J, Martínez-Cabriales SA, Garza-Rodríguez V. An Update on Calciphylaxis. Am J Clin Dermatol 2018; 19:599-608. [PMID: 29808451 DOI: 10.1007/s40257-018-0361-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy and uremic small artery disease with medial wall calcification and intimal hyperplasia, is a multifactorial cutaneous vascular disease characterized by chronic, painful, non-healing wounds that occur frequently in patients with chronic kidney disease, predominantly in those with end-stage renal disease. The pathogenesis remains unclear, and the development of calciphylaxis lesions depends on medial calcification, intimal fibrosis of arterioles and thrombotic occlusion. Despite an increase in reports of calciphylaxis in the literature and clinical recognition of demographic characteristics and risk factors associated with calciphylaxis, it remains a poorly understood disease with high morbidity and mortality. In this review, we analyze and summarize the clinical manifestations, pathogenesis and pathophysiology, histopathology, differential diagnosis, diagnostic workup and treatment modalities for calciphylaxis. Because of the lack of consensus regarding the optimal approach to and treatment of this disorder, a high degree of clinical suspicion, early diagnosis, and multimodal and multidisciplinary treatment in collaboration with dermatology, nephrology, wound care, nutrition and pain management specialties may improve survival in patients with calciphylaxis.
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Basnet S, Tachamo N, Dhital R, Tharu B. Multifactorial aetiology for non-uremic calciphylaxis: a case report. J Community Hosp Intern Med Perspect 2018; 8:163-166. [PMID: 29915661 PMCID: PMC5998291 DOI: 10.1080/20009666.2018.1479617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/17/2018] [Indexed: 10/27/2022] Open
Abstract
Calciphylaxis is commonly associated with end-stage renal disease patients on haemodialysis. We present a rare case of calciphylaxis in a non-uremic patient. The diagnosis was made clinically and confirmed with skin biopsy showing calcification of the dermal and subcutaneous tissues in the von Kossa stain. We believe that the combination of uncontrolled diabetes mellitus, a non-functioning paraganglioma and vitamin D deficiency in a susceptible female patient was responsible for causing calciphylaxis in our patient. An index of suspicion should be maintained by clinicians for calciphylaxis even in patients without uremia.
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Affiliation(s)
- Sijan Basnet
- Department of Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Niranjan Tachamo
- Department of Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Rashmi Dhital
- Department of Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Biswaraj Tharu
- Maharajgunj Medical Campus, Tribhuvan University, Kathmandu, Nepal
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De Flammineis E, Mulvaney PM, Kraft S, Mihm MC, Das S, Kroshinsky D. A 71-Year-Old Female with Myocardial Infarction and Long-Standing Ulcers on the Thigh. Dermatopathology (Basel) 2018; 4:18-23. [PMID: 29456997 PMCID: PMC5803738 DOI: 10.1159/000481727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Calciphylaxis is most commonly encountered in patients with end-stage renal disease; however, it is increasingly observed in nonuremic patients as well. It is important to consider and diagnose nonuremic calciphylaxis early, as prompt treatment and mitigation of associated risk factors is essential to improve long-term outcomes for these patients. Here, we present the case of a 71-year-old woman with atrial fibrillation on warfarin, but without renal disease, who presented with two long-standing ulcers on her thigh and was diagnosed with the aid of biopsy with calciphylaxis. We review the existing literature on the subject and offer this case as a representative report of a clinicopathologic correlation for this disorder.
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Affiliation(s)
| | - Patrick M Mulvaney
- Harvard Combined Dermatology Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | - Stefan Kraft
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Martin C Mihm
- Department of Dermatology and Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Shinjita Das
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
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Penn LA, Brinster N. Calciphylaxis with pseudoxanthoma elasticum-like changes: A case series. J Cutan Pathol 2017; 45:118-121. [DOI: 10.1111/cup.13075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 10/21/2017] [Accepted: 10/26/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Lauren A. Penn
- The Ronald O. Perelman Department of Dermatology, Section of Dermatopathology; New York University; New York New York
| | - Nooshin Brinster
- The Ronald O. Perelman Department of Dermatology, Section of Dermatopathology; New York University; New York New York
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Cassius C, Moguelet P, Monfort J, Fessi H, Michel P, Boulahia G, Cury K, Frances C, Senet P. Calciphylaxis in haemodialysed patients: diagnostic value of calcifications in cutaneous biopsy. Br J Dermatol 2017; 178:292-293. [DOI: 10.1111/bjd.15655] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C. Cassius
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P. Moguelet
- Department of Pathology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - J.B. Monfort
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - H. Fessi
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P.A. Michel
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - G. Boulahia
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - K. Cury
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - C. Frances
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P. Senet
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
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21
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Dobry A, Ko L, Kroshinsky D. Fractures in calciphylaxis patients following intravenous sodium thiosulfate therapy. J Eur Acad Dermatol Venereol 2017; 31:e445-e446. [DOI: 10.1111/jdv.14255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- A.S. Dobry
- Department of Dermatology, Massachusetts General Hospital; Harvard Medical School; 50 Staniford Street 2nd Floor Boston MA USA
| | - L.N. Ko
- Department of Dermatology, Massachusetts General Hospital; Harvard Medical School; 50 Staniford Street 2nd Floor Boston MA USA
| | - D. Kroshinsky
- Department of Dermatology, Massachusetts General Hospital; Harvard Medical School; 50 Staniford Street 2nd Floor Boston MA USA
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Martineau P, Pelletier-Galarneau M, Bazarjani S. The Role of Bone Scintigraphy with Single-photon Emission Computed Tomography-computed Tomography in the Diagnosis and Evaluation of Calciphylaxis. World J Nucl Med 2017; 16:172-174. [PMID: 28553189 PMCID: PMC5436328 DOI: 10.4103/1450-1147.203076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy, is an uncommon disease, typically found in patients with the end-stage renal disease. Pathophysiological features include small vessel vasculopathy with mural calcification, fibrosis, and thrombosis. The clinical presentation varies but often consists of the necrosis of skin and subcutaneous tissues, with or without visceral organ involvement due to small vessel vasculopathy. This condition has a significant morbidity and mortality, making accurate diagnosis imperative. We present a case of calciphylaxis investigated using planar bone scintigraphy and single-photon emission computed tomography-computed tomography (SPECT-CT). This case stresses the value of SPECT-CT to accurately localize the abnormal uptake in subcutaneous soft tissue microcalcifications and confirms the exact location and extent of pathology.
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Affiliation(s)
- Patrick Martineau
- Department of Nuclear Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Sadri Bazarjani
- Department of Nuclear Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Erdel BL, Juneja R, Evans-Molina C. A case of calciphylaxis in a patient with hypoparathyroidism and normal renal function. Endocr Pract 2016; 20:e102-5. [PMID: 24518186 DOI: 10.4158/ep13509.cr] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To present the case of a patient with a history of thyroid cancer, postsurgical hypoparathyroidism, chronic calcitriol use, and normal renal function who presented with painful skin lesions secondary to calciphylaxis. METHODS We describe the history, biochemistry, histopathology, evaluation, and management of this patient. RESULTS A 47-year-old female with hypoparathyroidism, chronically treated with calcitriol and calcium, presented with exquisitely painful skin ulcerations. Four months prior to the onset of symptoms, she had initiated warfarin therapy for atrial fibrillation. Review of laboratory data from the past year revealed elevated calcium and phosphorus levels. A diagnosis of calciphylaxis was made based upon pathologic evaluation of a skin biopsy. Management included titration of calcitriol and calcium to maintain serum calcium and phosphate levels in the low-normal range. Sodium thiosulfate was administered at a dose of 25 mg intravenously 3 times a week with some resolution in the patient's pain. Unfortunately, the patient battled recurrent bacteremia and sepsis, presumably related to her calciphylaxis wounds, and ultimately succumbed to complications from sepsis. CONCLUSION Although calciphylaxis is typically associated with renal insufficiency and secondary hyperparathyroidism, we highlight the case of a patient with normal renal function and hypoparathyroidism. Patients treated with chronic calcitriol should have serum calcium and phosphorus monitored closely and may benefit from non-calcium-based phosphate binders if hyperphosphatemia becomes unavoidable. This is especially important in the presence of other risk factors for calciphylaxis, including warfarin use.
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Affiliation(s)
- Blake L Erdel
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rattan Juneja
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carmella Evans-Molina
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana Department of Biochemistry, Indiana University School of Medicine, Indianapolis, Indiana Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana
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[Calciphylaxis. A review of 9 cases]. Med Clin (Barc) 2016; 147:157-61. [PMID: 27422736 DOI: 10.1016/j.medcli.2016.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 05/20/2016] [Accepted: 05/26/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Calciphylaxis is a cutaneous ischaemic vascular disease of small vessels with high morbidity and mortality. To date very few series of patients with this disease have been published, none from a Spanish hospital. The main objectives of this work are to analyze the demographic, clinical and histological profile of patients diagnosed in our department to identify risk factors and potential therapeutic strategies. MATERIAL AND METHOD We made a retrospective study of the cases seen in the dermatology department with a diagnosis of calciphylaxis and who had a confirmatory biopsy in the period between January 2010 to August 2015. RESULTS Nine patients were studied, with an age range of 76-86 years. All had cardiovascular comorbidities and 67% had renal failure. A 33% mortality was observed. CONCLUSIONS Faced with a possible diagnosis of calciphylaxis, a complete blood analysis is mandatory to rule out other causes of skin ulcers. The management of these patients should be undertaken by a multidisciplinary team. We emphasize the role of sodium thiosulfate in the treatment of this condition.
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Abstract
PURPOSE OF REVIEW Calcific uremic arteriolopathy (CUA), as known as calciphylaxis, is a rare and poorly understood disease seen predominantly in end stage renal disease patients. A collaborative multidisciplinary approach to develop and implement treatment and prevention methods is described. RECENT FINDINGS Overall, the scientific literature on CUA is largely restricted to case reports and case series. Recent reports indicate that the incidence of CUA may be on the rise and emphasize an association with vitamin K antagonist therapy, obesity, and diabetes mellitus. Serum calcium, phosphorous, and parathyroid hormone levels have been reported to be quite variable in patients with CUA and may reflect the heterogeneity of study designs. A multidisciplinary and multimodal approach that incorporates wound and pain management, sodium thiosulfate, optimization of mineral bone parameters, bisphosphonates, and avoidance of risk factors such as vitamin K antagonist has been advocated in the latest reports. Sodium thiosulfate although used frequently to treat CUA has unclear efficacy requiring further examination. SUMMARY This review describes the recent literature in the field of CUA including its limitations. It provides a summary of a multidisciplinary approach to CUA management.
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Jawad AS. Non-uraemic calciphylaxis - an unexpected differential diagnosis for a necrotic ulcer. Clin Med (Lond) 2016; 16:207. [PMID: 27037400 PMCID: PMC4952984 DOI: 10.7861/clinmedicine.16-2-207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bonchak JG, Park KK, Vethanayagamony T, Sheikh MM, Winterfield LS. Calciphylaxis: a case series and the role of radiology in diagnosis. Int J Dermatol 2015; 55:e275-9. [PMID: 26518613 DOI: 10.1111/ijd.13043] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 02/26/2015] [Accepted: 03/16/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Calciphylaxis is a syndrome of vascular calcification most commonly affecting patients with end-stage renal disease (ESRD) on hemodialysis. Because of its high mortality rate, early diagnosis and treatment are necessary. Although diagnosis is usually based on skin biopsy, histopathology is often nonspecific. As the role of imaging in calciphylaxis has not been studied extensively, we examined the utility of radiology in the diagnosis of this disease. METHODS A thorough review of electronic medical records for 2005-2013 at Loyola University Medical Center yielded 10 patients with biopsy-proven calciphylaxis. Using the radiological picture archiving and communication system (PACS), all imaging studies of the affected body part obtained within 6 months of diagnosis were analyzed and tabulated. RESULTS All 10 patients had undergone imaging (computed tomography, ultrasound, plain radiography, and/or mammography) of the affected anatomy prior to diagnosis by skin biopsy. Nine of these patients were noted to have moderate-to-severe soft tissue vascular calcification in the area of skin biopsy. CONCLUSIONS This case series supports the suggestion that findings of superficial vascular calcifications on imaging studies are sensitive for the diagnosis of calciphylaxis. Used in conjunction with histopathological, clinical, and laboratory data, radiology can serve an important role in the diagnosis of calciphylaxis.
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Affiliation(s)
- Jonathan G Bonchak
- Division of Dermatology, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Kelly K Park
- Division of Dermatology, Loyola University Medical Center, Maywood, IL, USA
| | | | - M Mukarram Sheikh
- Department of Radiology, Loyola University Medical Center, Maywood, IL, USA
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Lloyd WR, Agarwal S, Nigwekar SU, Esmonde-White K, Loder S, Fagan S, Goverman J, Olsen BR, Jumlongras D, Morris MD, Levi B. Raman spectroscopy for label-free identification of calciphylaxis. JOURNAL OF BIOMEDICAL OPTICS 2015; 20:80501. [PMID: 26263412 PMCID: PMC4689104 DOI: 10.1117/1.jbo.20.8.080501] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 07/17/2015] [Indexed: 06/04/2023]
Abstract
Calciphylaxis is a painful, debilitating, and premorbid condition, which presents as calcified vasculature and soft tissues. Traditional diagnosis of calciphylaxis lesions requires an invasive biopsy, which is destructive, time consuming, and often leads to exacerbation of the condition and infection. Furthermore, it is difficult to find small calcifications within a large wound bed. To address this need, a noninvasive diagnostic tool may help clinicians identify ectopic calcified mineral and determine the disease margin. We propose Raman spectroscopy as a rapid, point-of-care, noninvasive, and label-free technology to detect calciphylaxis mineral. Debrided calciphylactic tissue was collected from six patients and assessed by microcomputed tomography (micro-CT). Micro-CT confirmed extensive deposits in three specimens, which were subsequently examined with Raman spectroscopy. Raman spectra confirmed that deposits were consistent with carbonated apatite, consistent with the literature. Raman spectroscopy shows potential as a noninvasive technique to detect calciphylaxis in a clinical environment.
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Affiliation(s)
- William R. Lloyd
- University of Michigan, Department of Chemistry, 930 North University Avenue, Ann Arbor, Michigan 48109, United States
| | - Shailesh Agarwal
- University of Michigan Medical School, Department of Surgery, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109, United States
| | - Sagar U. Nigwekar
- Massachusetts General Hospital, Department of Medicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Karen Esmonde-White
- University of Michigan Medical School, Department of Internal Medicine, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109, United States
| | - Shawn Loder
- University of Michigan Medical School, Department of Surgery, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109, United States
| | - Shawn Fagan
- Massachusetts General Hospital, Department of Surgery, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Jeremy Goverman
- Massachusetts General Hospital, Department of Surgery, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Bjorn R. Olsen
- Harvard University School of Dental Medicine, Department of Developmental Biology, 188 Longwood Avenue, Boston, Massachusetts 02115, United States
| | - Dolrudee Jumlongras
- Harvard University School of Dental Medicine, Department of Developmental Biology, 188 Longwood Avenue, Boston, Massachusetts 02115, United States
| | - Michael D. Morris
- University of Michigan, Department of Chemistry, 930 North University Avenue, Ann Arbor, Michigan 48109, United States
| | - Benjamin Levi
- University of Michigan Medical School, Department of Surgery, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109, United States
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Nigwekar SU, Kroshinsky D, Nazarian RM, Goverman J, Malhotra R, Jackson VA, Kamdar MM, Steele DJR, Thadhani RI. Calciphylaxis: risk factors, diagnosis, and treatment. Am J Kidney Dis 2015; 66:133-46. [PMID: 25960299 DOI: 10.1053/j.ajkd.2015.01.034] [Citation(s) in RCA: 251] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/22/2015] [Indexed: 02/07/2023]
Abstract
Calciphylaxis is a rare but devastating condition that has continued to challenge the medical community since its early descriptions in the scientific literature many decades ago. It is predominantly seen in patients with chronic kidney failure treated with dialysis (uremic calciphylaxis) but is also described in patients with earlier stages of chronic kidney disease and with normal kidney function. In this review, we discuss the available medical literature regarding risk factors, diagnosis, and treatment of both uremic and nonuremic calciphylaxis. High-quality evidence for the evaluation and management of calciphylaxis is lacking at this time due to its rare incidence and poorly understood pathogenesis and the relative paucity of collaborative research efforts. We hereby provide a summary of recommendations developed by a multidisciplinary team for patients with calciphylaxis.
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Affiliation(s)
- Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, MA.
| | | | - Rosalynn M Nazarian
- Pathology Service, Dermatopathology Unit, Massachusetts General Hospital, Boston, MA
| | - Jeremy Goverman
- Burn Service, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Rajeev Malhotra
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Vicki Ann Jackson
- Palliative Care Division, Massachusetts General Hospital, Boston, MA
| | - Mihir M Kamdar
- Palliative Care Division, Massachusetts General Hospital, Boston, MA
| | - David J R Steele
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
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de Barbieri I, Baumann J, Casal MC, Gurevich A, Pancirova J, Poulia KA, Riemann A. AN OVERVIEW OF NURSES' MANAGEMENT OF SECONDARY HYPERPARATHYROIDISM: HOW IS EUROPE DOING? J Ren Care 2015; 41:202-10. [PMID: 25899821 DOI: 10.1111/jorc.12120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nurses have an important role to play in the management of secondary hyperparathyroidism (SHPT). An online survey conducted by the European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) in conjunction with Amgen (Europe) GmbH surveyed nephrology nurses' knowledge of secondary hyperparathyroidism, treatment targets, current treatments, patient adherence and nephrology nurse training education needs. The survey's aim was to establish common practices being used by nurses in the management of secondary hyperparathyroidism and to identify nephrology nurses' training and educational needs in order to improve patient care. METHODS DESIGN Descriptive study. MEASUREMENTS An online survey of multiple choice and closed questions. PARTICIPANTS A sample of nephrology nurses from Spain, Italy, France and the Netherlands. RESULTS A total of 111 nurses completed the questionnaire (98% response rate, 82% of which were fully completed). Collected data revealed that there were specific aspects of SHPT patient management where nurses lacked confidence, despite the majority of respondents having 15 years nephrology nursing experience. These aspects included explaining the disorder and therapies to patients, managing side effects of drugs and appreciating the significance of controlling biochemical targets. Over 40% of the respondents felt they did not have sufficient training to support patients who were non-compliant. CONCLUSION Nursing skills are integral to SHPT patient management as part of the multidisciplinary approach. The nurse's role is particularly important in patient assessment and monitoring, and in the provision of patient education and support, particularly with treatment adherence. Nephrology nurses who are better informed about SHPT and who receive training on practical patient care may improve the care of patients.
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Affiliation(s)
| | | | | | | | | | | | - Aase Riemann
- Independent Renal Nurse Consultant, Amsterdam, the Netherlands
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Nigwekar SU, Solid CA, Ankers E, Malhotra R, Eggert W, Turchin A, Thadhani RI, Herzog CA. Quantifying a rare disease in administrative data: the example of calciphylaxis. J Gen Intern Med 2014; 29 Suppl 3:S724-31. [PMID: 25029979 PMCID: PMC4124115 DOI: 10.1007/s11606-014-2910-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Calciphylaxis, a rare disease seen in chronic dialysis patients, is associated with significant morbidity and mortality. As is the case with other rare diseases, the precise epidemiology of calciphylaxis remains unknown. Absence of a unique International Classification of Diseases (ICD) code impedes its identification in large administrative databases such as the United States Renal Data System (USRDS) and hinders patient-oriented research. This study was designed to develop an algorithm to accurately identify cases of calciphylaxis and to examine its incidence and mortality. DESIGN, PARTICIPANTS, AND MAIN MEASURES Along with many other diagnoses, calciphylaxis is included in ICD-9 code 275.49, Other Disorders of Calcium Metabolism. Since calciphylaxis is the only disorder listed under this code that requires a skin biopsy for diagnosis, we theorized that simultaneous application of code 275.49 and skin biopsy procedure codes would accurately identify calciphylaxis cases. This novel algorithm was developed using the Partners Research Patient Data Registry (RPDR) (n = 11,451 chronic hemodialysis patients over study period January 2002 to December 2011) using natural language processing and review of medical and pathology records (the gold-standard strategy). We then applied this algorithm to the USRDS to investigate calciphylaxis incidence and mortality. KEY RESULTS Comparison of our novel research strategy against the gold standard yielded: sensitivity 89.2%, specificity 99.9%, positive likelihood ratio 3,382.3, negative likelihood ratio 0.11, and area under the curve 0.96. Application of the algorithm to the USRDS identified 649 incident calciphylaxis cases over the study period. Although calciphylaxis is rare, its incidence has been increasing, with a major inflection point during 2006-2007, which corresponded with specific addition of calciphylaxis under code 275.49 in October 2006. Calciphylaxis incidence continued to rise even after limiting the study period to 2007 onwards (from 3.7 to 5.7 per 10,000 chronic hemodialysis patients; r = 0.91, p = 0.02). Mortality rates among calciphylaxis patients were noted to be 2.5-3 times higher than average mortality rates for chronic hemodialysis patients. CONCLUSIONS By developing and successfully applying a novel algorithm, we observed a significant increase in calciphylaxis incidence. Because calciphylaxis is associated with extremely high mortality, our study provides valuable information for future patient-oriented calciphylaxis research, and also serves as a template for investigating other rare diseases.
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Borges L, Rosa P, Dias E, Cássio I. Successful treatment of calciphylaxis by a multidisciplinary approach. BMJ Case Rep 2014; 2014:bcr-2014-204354. [PMID: 25035446 DOI: 10.1136/bcr-2014-204354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 48-year-old woman performing peritoneal dialysis for end-stage renal disease presented with a painful leg ulcer. The investigation revealed an elevated parathyroid hormone level and the histological examination of the biopsy tissue from the ulcer revealed medial calcification of the arterioles, consistent with calciphylaxis. The patient developed additional ulcers in the lower limbs and treatment with antibiotics, cinacalcet, sevelamer, sodium thiosulfate, low calcium dialysate and hyperbaric oxygen therapy was instituted. The patient had a favourable outcome and after 9 months the ulcers had healed and the parathyroid hormone level reached the normal range. Calciphylaxis is a rare and life-threatening disorder associated with a mortality of 60-80%. Its pathogenesis is not fully understood hence there is no consensus in the treatment of this pathology.
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Affiliation(s)
- Lisa Borges
- Department of Vascular Surgery, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Pedro Rosa
- Hyperbaric Medicine Department, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Emanuel Dias
- Department of Angiology and Vascular Surgery, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Isabel Cássio
- Department of Angiology and Vascular Surgery, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
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Cai MMX, Smith ER, Brumby C, McMahon LP, Holt SG. Fetuin-A-containing calciprotein particle levels can be reduced by dialysis, sodium thiosulphate and plasma exchange. Potential therapeutic implications for calciphylaxis? Nephrology (Carlton) 2013; 18:724-7. [DOI: 10.1111/nep.12137] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Michael MX Cai
- Department of Renal Medicine; Eastern Health; Melbourne Victoria Australia
| | | | - Catherine Brumby
- Department of Renal Medicine; Eastern Health; Melbourne Victoria Australia
| | - Lawrence P McMahon
- Department of Renal Medicine; Eastern Health; Melbourne Victoria Australia
- Monash University; Melbourne Victoria Australia
| | - Stephen G Holt
- Monash University; Melbourne Victoria Australia
- The Royal Melbourne Hospital; Melbourne Victoria Australia
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Azegami T, Wakino S, Hayashi M, Itoh H. Severe systemic calciphylaxis with culture-negative endocarditis. Clin Kidney J 2013; 6:342-3. [PMID: 26064499 PMCID: PMC4400473 DOI: 10.1093/ckj/sft019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 02/07/2013] [Indexed: 11/13/2022] Open
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Gupta D, Tadros R, Mazumdar A, Moiin A, Fuleihan SF. Breast Lesions with Intractable Pain in End-Stage Renal Disease: Calciphylaxis with Chronic Hypotensive Dermatopathy Related Watershed Breast Lesions. J Palliat Med 2013; 16:551-4. [DOI: 10.1089/jpm.2012.0495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Deepak Gupta
- Department of Anesthesiology, Detroit Medical Center, Wayne State University, Detroit, Michigan
| | - Raouf Tadros
- Department of Anesthesiology, Detroit Medical Center, Wayne State University, Detroit, Michigan
| | - Ashish Mazumdar
- Department of Anesthesiology, Detroit Medical Center, Wayne State University, Detroit, Michigan
| | - Ali Moiin
- Department of Dermatology, Detroit Medical Center, Wayne State University, Detroit, Michigan
| | - Samir F. Fuleihan
- Department of Anesthesiology, Detroit Medical Center, Wayne State University, Detroit, Michigan
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Akai A, Okamoto H, Shigematsu K, Miyata T, Watanabe T. Revascularization surgery for penile calciphylaxis. J Vasc Surg 2013; 58:1665-7. [PMID: 23571078 DOI: 10.1016/j.jvs.2013.02.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 12/05/2012] [Accepted: 02/12/2013] [Indexed: 11/29/2022]
Abstract
Calciphylaxis, a systemic disorder seen in 1%-4% of patients with end-stage renal disease, is a cause of penile ischemic gangrene. We present a case of successful revascularization surgery for penile calciphylaxis. An arterial bypass to the deep dorsal penile vein relieved the rest pain and stopped expansion of the gangrenous lesion.
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Affiliation(s)
- Atsushi Akai
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Yalin AS, Altiparmak MR, Trabulus S, Yalin SF, Yalin GY, Melikoglu M. Calciphylaxis: a report of six cases and review of literature. Ren Fail 2012; 35:163-9. [PMID: 23151146 DOI: 10.3109/0886022x.2012.741426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Calciphylaxis is usually a fatal condition that develops in a few chronic renal failure patients, and it is characterized by calcifications in subcutaneous arteries, infarcts in skin, and the neighboring subcutis. Calciphylaxis, once considered as a rare condition, has been reported to have an annual incidence of 1% and a prevalence of 4% in dialysis patients. We describe our clinical experience in six end-stage renal disease patients on dialysis that presented with calciphylaxis and died due to sepsis, and review the pathogenesis, epidemiology, clinical and histopathologic features, and treatment of calciphylaxis. Physicians should initially consider the possibility of calciphylaxis in case of development of skin lesions in chronic renal failure patients with impaired calcium, phosphorus, and parathyroid hormone levels. The most important cause of mortality in this condition is infection. Therefore, differential diagnosis of these lesions from systemic vasculitis in their early stages and withdrawal of immunosuppressive therapy that increases the tendency to infections are essential.
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Affiliation(s)
- Ayse Serap Yalin
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Marshall BJ, Johnson RE. Case Report on Calciphylaxis: An Early Diagnosis and Treatment May Improve Outcome. J Am Coll Clin Wound Spec 2012; 4:67-70. [PMID: 26236639 PMCID: PMC4511548 DOI: 10.1016/j.jccw.2013.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This is a case report of a patient who presented to the wound care center with LE ulcerations that were subsequently diagnosed with calciphylaxis. She was an insulin dependent diabetic with renal disease, but unaware of her critical kidney status. She was treated with local wound care, a partial parathyroidectomy, and started on dialysis. She is currently healed with no recurrence of ulcerations. Her ulcerations were controlled with conservative wound care and no surgical debridement.
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Affiliation(s)
| | - Rachel E. Johnson
- Department of Kent State University College of Podiatric Medicine, 6000 Rockside Woods Blvd., Independence, OH 44131, USA
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Sibai H, Ishak RS, Halawi R, Otrock ZK, Salman S, Abu-Alfa A, Kharfan-Dabaja MA. Non-uremic calcific arteriolopathy (calciphylaxis) in relapsed/refractory Hodgkin's lymphoma: a previously unreported association. J Clin Oncol 2012; 30:e88-90. [PMID: 22231039 DOI: 10.1200/jco.2011.39.4551] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Hassan Sibai
- American University of Beirut Medical Center, Beirut, Lebanon
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Life-Threatening Hypocalcemia following Subtotal Parathyroidectomy in a Patient with Renal Failure and Previous Roux-en-Y Gastric Bypass Surgery. Case Rep Endocrinol 2011; 2011:370583. [PMID: 22937282 PMCID: PMC3420727 DOI: 10.1155/2011/370583] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Accepted: 10/02/2011] [Indexed: 01/14/2023] Open
Abstract
Background. Roux-en-Y gastric bypass (RYGB) can result in calcium and vitamin D deficiency. Parathyroid surgery carries the risk of immediate and long-term hypocalcemia. Methods and Results. We describe a 54-year-old woman with history of end-stage renal disease and gastric bypass surgery who developed calciphylaxis requiring a 3.5-gland parathyroidectomy. Seven weeks later, she presented with weakness, perioral numbness, leg cramps, a positive Chvostek's sign, hypotension, prolonged QT-interval, and serum calcium of 5.4 mg/dL. Oral and intravenous calcium, calcitriol, and high calcium bath hemodialysis were given. She required 18 days of intravenous calcium and an outpatient maintenance regimen of calcitriol 6 mcg/day, calcium carbonate 8 grams/day, calcium citrate 1.2 grams/day, and ergocalciferol 50,000 IU/week. Conclusion. The patient's life-threatening prolonged hypocalcemia and large requirements of calcium and calcitriol were due to a combination of malabsorption, hypoparathyroidism, and renal failure. Special considerations should be given to bariatric surgery patients undergoing neck exploration.
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Aliaga LG, Barreira JC. Calciphylaxis in a patient with systemic lupus erythematosus without renal insufficiency or hyperparathyroidism. Lupus 2011; 21:329-31. [PMID: 21997968 DOI: 10.1177/0961203311420316] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Calciphylaxis is a frequent entity in patients with chronic renal failure of diverse etiology. The main pathogenic mechanism of calciphylaxis is impairment of either calcium and phosphate metabolism or plasma levels of parathyroid hormone. There are communications of patients with normal renal function, and in some cases with chronic inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosus (SLE) and antiphospholipid syndrome. We report a patient with SLE and no renal failure or hyperparathyroidism who developed severe calciphylaxis.
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Affiliation(s)
- L G Aliaga
- Rheumatology Unit, Hospital Británico de Buenos Aires, Buenos Aires, Argentina.
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Gerhardt CMB, Gussão BC, de Matos JPS, Lugon JR, Pinto JMN. [Skin diseases in hemodialysis and kidney transplant patients]. J Bras Nefrol 2011; 33:268-75. [PMID: 21789446 DOI: 10.1590/s0101-28002011000200024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 04/24/2011] [Indexed: 11/22/2022] Open
Abstract
Recently, the world is facing an escalate in the incidence of chronic kidney disease (CKD). Databases containing information about patients in end stage renal disease (ESRD), especially in the United States, were the sources of initial information about it. Brazil has the third largest population on dialysis in the world, and there are about 680 dialysis centers, spread across all units of the federation in the present, providing treatment to an estimated population of almost 90,000 patients. Cutaneous involvement in the chronic renal failure is characterized by a number of manifestations, which may be related to three processes: the primary renal disease, the uremic state, or the therapeutic measures used in their handling. The skin changes in these two classes of patients, dialysis and transplant recipients, have been the subject of several studies. n recent years, however, great progress has been achieved in these two therapeutic modalities, which may have changed not only the type of the dermatologic disorders associated with these two conditions, but also their intensity or frequency. This article aims to yield an update as to the topic skin diseases in hemodialysis and kidney transplant patients.
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Rezaie W, Overtoom HAJM, Flens M, Klaassen RJL. Calciphylaxis in chronic renal failure: An approach to risk factors. Indian J Nephrol 2011; 19:115-8. [PMID: 20436732 PMCID: PMC2859477 DOI: 10.4103/0971-4065.57109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of calcifying panniculitis due to calciphylaxis in a nontherapy compliance 65-year-old man suffering from chronic renal failure. Calciphylaxis, a life threatening condition, is characterized by high calcium x phosphate product, presence of calcium crystals in the skin and secondary hyperparathyroidism. The clinical presentation includes painful firm plaques, which could progress to nonhealing ulcers. A review of literature is given with emphasis on identification of risk factors and early diagnosis.
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Affiliation(s)
- W Rezaie
- Department of Internal Medicine, Zaans Medical Center, The Netherlands
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Abstract
Retiform purpura consists of branching purpuric lesions caused by a complete blockage of blood flow in the dermal and subcutaneous vasculature. The differential diagnosis for retiform purpura is broad, including vasculitides of the small and medium vessels as well as microvascular occlusion due to thrombotic, infectious, and embolic phenomena. Determining the etiology of this important dermatologic sign can be a diagnostic challenge; however, an organized approach can improve the speed and accuracy of diagnosis and identify an effective treatment. This review focuses on early recognition, evaluation, and treatment of hospitalized patients with retiform purpura. Specifically, vasculitis, protein C and S deficiencies, heparin necrosis, warfarin necrosis, antiphospholipid antibody syndrome, disseminated intravascular coagulation, cryoglobulinemia, calciphylaxis, and cholesterol embolization syndrome will be discussed in detail. These conditions are commonly seen in consultative dermatology and can have multiorgan involvement, complicated laboratory evaluation, and long-term therapeutic implications.
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Affiliation(s)
- Ashley Wysong
- Department of Dermatology, Stanford University, Stanford, CA, USA
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Abstract
OBJECTIVE To discuss when and how to workup calciphylaxis for early diagnosis and to delineate medical vs surgical management of the disease. METHODS Review of evidence-based medical literature on calciphylaxis due to primary, secondary, and tertiary hyperparathyroidism. RESULTS Calciphylaxis is usually associated with secondary and tertiary hyperparathyroidism. However, calciphylaxis can also be seen in the absence of chronic renal failure and has been reported in patients with primary hyperparathyroidism due to a parathyroid adenoma or carcinoma. Calciphylaxis occurs when the levels of calcium and phosphate in the blood exceed their solubility level, leading to calcium-phosphate deposits in arteries that compromise the vasculature. These ischemic changes result in plaque-like lesions that progress to painful nodules. Calciphylaxis is diagnosed on the basis of physical examination, laboratory, and histopathologic findings. When medical therapy has failed in the setting of secondary/tertiary hyperparathyroidism with calciphylaxis, parathyroidectomy is the preferred treatment. In primary hyperparathyroidism, early recognition and aggressive wound care with debridement are important in managing this condition. However, resection of the offending parathyroid gland should be strongly considered. CONCLUSIONS When calciphylaxis is present, early detection is critical to the successful management of this condition. Although medical therapy can be effective, surgical resection of the diseased parathyroid glands can be curative and potentially life saving. A multidisciplinary approach involving early diagnosis, aggressive medical management, operative debridement, and parathyroidectomy has the best chance of improving survival in calciphylaxis.
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Affiliation(s)
- Rashmi Roy
- Department of Endocrine Surgery, Johns Hopkins University, Baltimore, Maryland 21287, USA.
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Abstract
Calciphylaxis represents a dermatological emergency with a mortality of up to 80%. The disease is characterized by a triad of arteriolar medial calcification, thrombotic cutaneous ischemia and necrotic ulcerations. Recently several mechanisms of vascular calcification have been identified. This may led to preventive measures in the future. Early diagnosis is important to avoid complications such as sepsis. The dermatologist plays an important role in early diagnosis based on the recognition of clinical presentation and histopathology. Patients with end-stage renal disease are most commonly affected by calciphylaxis. The most frequent non-uremic predisposing conditions are primary hyperparathyroidism, malignancies, alcohol-induced liver disease, and autoimmune connective tissue diseases. Medical treatment aims to normalize mineral metabolism to reduce the serum concentration of sodium phosphate and thus to prevent precipitation and calcification. Newer compounds are bisphosphonates, non-sodium/non-aluminium phosphate binders, cinacalcet, paricalcitrol, and sodium thiosulfate. Among the surgical procedures parathyroidectomy did not result in a significant survival benefit. An aggressive surgical debridement of necrotic ulcerations, on the other hand, improved survival. Early diagnosis and a multidisciplinary treatment approach including re-vascularization by the vascular surgeon, repeated surgical debridement and split skin transplantation support wound healing and insure limb conservation.
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Affiliation(s)
- U Wollina
- Klinik für Dermatologie und Allergologie, Krankenhaus Dresden-Friedrichstadt, Städtisches Klinikum, Akademisches Lehrkrankenhaus der Technischen Universität Dresden, Friedrichstr. 41, 01067, Dresden.
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Magro CM, Simman R, Jackson S. Calciphylaxis: a review. THE JOURNAL OF THE AMERICAN COLLEGE OF CERTIFIED WOUND SPECIALISTS 2011; 2:66-72. [PMID: 24527153 DOI: 10.1016/j.jcws.2011.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Human calciphylaxis reflects a form of severe tissue compromise attributable to a unique microangiopathy that combines features of vascular thrombotic occlusion with endoluminal calcification. While most frequently described in patients with renal failure, it is seen in other settings, such as multiple myeloma; polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes (POEMS) syndrome; cirrhosis; and rheumatoid arthritis. Although most commonly involving the skin, calciphylaxis can affect other organs including the heart and gastrointestinal tract, in which cases it falls under the appellation of systemic calciphylaxis. There are cases in which the main pathology is one of endovascular thrombosis of the vessels of the fat without discernible calcification or one manifesting a pseudoangiosarcomatous pattern, hence adding to the histomorphologic spectrum of calciphylaxis. A variety of factors contribute to this severe occlusive microangiopathy, including an underlying procoagulant state and ectopic neo-osteogenesis of the microvasculature through varied mechanisms, including increased osteopontin production by vascular smooth muscle or reduced synthesis of fetuin and GLA matrix protein, important inhibitors of ectopic neo-osteogenesis. Certain factors adversely affect outcome, including truncal and genital involvement and systemic forms of calciphylaxis. With a better understanding of its pathophysiology, more-effective therapies, such as sodium thiosulfate and biphosphanates to reduce reactive oxygen species and receptor activator of nuclear factor κβ-mediated nuclear factor κβ activity, respectively, are being developed.
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Affiliation(s)
- Cynthia M Magro
- Department of Pathology and Laboratory Medicine, Weil Medical College of Cornell University, New York, NY 10065, USA
| | - Richard Simman
- Department of Pharmacology and Toxicology at Wright State University Boonshoft School of Medicine, Dayton, OH 45324, USA
| | - Sarah Jackson
- Kettering Medical Center Internal Medicine, Kettering, OH 45429, USA
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Goel SK, Bellovich K, McCullough PA. Treatment of severe metastatic calcification and calciphylaxis in dialysis patients. Int J Nephrol 2011; 2011:701603. [PMID: 21423552 PMCID: PMC3056381 DOI: 10.4061/2011/701603] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 12/20/2010] [Indexed: 11/20/2022] Open
Abstract
Metastatic calcification is a frequent complication encountered in patients undergoing maintenance dialysis and has a complex pathogenesis. It is often difficult to treat and is associated with high morbidity and mortality. Early recognition and prompt initiation of treatment is vital. Local wound care and aggressive metabolic control remain the cornerstones of the therapy. Various novel treatment strategies including sodium thiosulfate and hyperbaric oxygen therapy have been utilized and reviewed in this paper. The response rate to treatment is poor and prevention is the best approach.
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Affiliation(s)
- Saurabh K Goel
- Division of Nephrology, St. John Providence Health System, St. John Hospital and Medical Center, 22201 Moross Road, Suite 150, Detroit, MI 48236, USA
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